Compliance actions and decertification risk from flawed recertification oversight

$10,000–$150,000 per year in uncollectible balances, refunded fees, and foregone reimbursement when care turns out to be ineligible for any payer due to missing certifications. • $150,000–$2,000,000 over several years in MA claim denials, retrospective recoupments, and unpaid visits when services continue without valid recertification or authorization, plus potential network sanctions or contract loss for systemic noncompliance. • $25,000–$250,000 per year in lost shared-savings, excluded episodes, and uncompensated care tied to questioned eligibility or missing recertification support.

Billing and OASIS specialist tracks upcoming recert and discharge dates manually with spreadsheets and paper tickler files, cross-checking OASIS, EMR, and payer portals by memory and ad-hoc email reminders to clinicians and physicians for late signatures or narratives. • Billing/OASIS specialist loosely tracks private-pay care plans and any potential coverage changes via spreadsheets and manual notes, reconstructing medical-necessity and eligibility documentation if a payer comes in after the fact. • Billing/OASIS specialist maintains payer-specific calendars and checklists in Excel and paper binders, manually compiling and uploading recert packets through insurer portals and reworking them if reviewers push back.